Health Care Renewal

Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Friday, September 22, 2017

These days, legislative efforts to change US health care, especially to "reform and replace" the Affordable Care Act [ACA or "Obamacare"] seem to inspire displays of jaw dropping ignorance by political and sometimes business leaders on behalf of "reforming" health care. We last posted examples on July 7, 2017. Now there is a new game afoot to reform and replace, and it is generating new - not to put too fine a point on it - foolishness.

So herein is a roundup of a two more examples from July after our last post, plus two more revently "ripped from the headlines," actually ripped from relatively obscure media articles, because the anechoic effect persists, and the media still does not cover these sort of things much. In chronological order:

Ohio Gov. John Kasich's (R) office has flatly rejected Vice President Pence's claim that nearly 60,000 disabled Ohioans are on waiting lists for Medicaid’s home and community-based services.

Kasich spokesman Jon Keeling told The Washington Post that such an assertion is 'not accurate' and that suggesting Medicaid expansion hurt the developmentally disabled system 'is false, as it is just the opposite of what actually happened.'

At that time, while the previous push to "repeal and replace" was still going on, and Vice President Pence was apparently trying to make a point about how bad "Obamacare" is:

'I know Gov. Kasich isn’t with us, but I suspect that he’s very troubled to know that in Ohio alone, nearly 60,000 disabled citizens are stuck on waiting lists, leaving them without the care they need for months or even years,' Pence said in a speech Friday at the National Governors Association summer meeting in Providence, R.I.

But,

According to the Post, waiting lists for such Medicaid services are common and are typically longer in states that did not take ObamaCare's Medicaid expansion than in those that did.

Ohio was among a number of Republican-controlled states that took the ACA's Medicaid expansion, which dramatically expanded the number of people who qualify for the program.

President Trump Makes Multiple Misleading Claims About His Efforts to Reform the Veterans Administration

We know that interesting things often happened at Mr Trump's campaign events, and at his later "campaign style" events as President. Stat reported on July 28, 2017:

President Trump paints a rosy picture of an improved Department of Veterans Affairs under his watch, where accessing electronic medical records is 'so easy and so good' and health care is freely available without any delays.

The problem: It’s not true.

At a campaign-style event in Ohio this week, Trump’s claims of progress were so overstated that even his own VA secretary, David Shulkin — who stood right next to him — would have to disagree.

The article went on to list a number of specific claims which were false or misleading, including:

- Claims that the VA had doubled the number of veterans given approval to see a "doctor of their choice" outside of the system. In fact, the troubled VA Choice program increased the number by only "26 percent", and the program was facing new budget problems at the time Mr Trump made the claim.

- Claims that the administration had published wait times for all VA sites. This actually started more than a year previously, under the Obama administration.

- Claims that the VA now offers same-day mental health services. "This may be the case, but it happened before Trump took office."

In the "good old days," vice presidents and presidents who spoke publicly about issues like health care, about which one could not expect them to be expert, might have sought detailed briefings and/ or deferred some issues to their own experts.

Donald Trump’s top economic advisor Stephen Moore on Tuesday demonstrated an apparent lack-of-knowledge of just how insurance works, telling CNBC’s John Harwood 'people want insurance for their own families, not other peoples.'
Moore was explaining why it’s unfair to have an insurance system where healthy people subsidize sick people.

Trump adviser Moore on unfairness of the healthy subsidizing the sick: 'people want insurance for their own families, not other peoples'
— John Harwood (@JohnJHarwood) September 19, 2017

Moore's implication seemed to be that people should not pay for insurance programs which might pay for health care for other people. Yet the simple minded notion of insurance is that it is a tool to pool the resources of the many to pay for costs that only some will incur during a given time period.

U.S. Sen. Ted Cruz, R-Texas, believes that people should be able to buy only the insurance that suits their needs. But there is no way anyone can ever know exactly what their needs will be, tomorrow, six months from now or six years from now.

You may not have diabetes or heart disease today, but a year from now, who knows?

A Trump economic adviser, Stephen Moore, said earlier this week, 'People want insurance for their own families, not other people’s families.'

He knows he is distorting how insurance works.

Our insurance premiums go to cover other people’s disasters as well as insure against our own.

That’s known as spreading the risk – the more people you can have in a pool of insureds, the more likely you’ll have affordable coverage for your own family.

I had a bad house fire in 1987 that cost about $50,000 to repair.

I certainly had not paid anywhere near $50,000 in homeowners’ insurance premiums up to that point (or ever).

Other people paid for my fire and I have helped pay for other people’s over the years.

We must have home and auto insurance, unless we don’t live in a house or drive.

We are all born and we all get sick and we all die, without exception, which is all the more reason for all of us to have affordable health insurance.

So here we had the example of a top executive branch adviser who apparently provides input about health insurance, yet who does not seem to understand what health insurance is.

Aetna CEO Wrongly States Canada Has a De Facto National Health Service in Which the Government Owns and Runs Hospitals and Physicians' Practices

[Aetna CEO Mark Bertolini] asked the room of investors and analysts to 'name a country that has single payer.'

When several participants named Canada, Bertolini disputed the answer and claimed that Canada has a 'government-run health care system. They’re not single payer, they’re single everything.'

But,

The suggestion, however, that Canada has a completely government-run health care system under which all medical professionals 'work for the government' is false. In Canada, medical claims for virtually all non-dental health care are paid by the government, but doctors and hospitals work in the private sector.

'Doctors in Canada are not employed by the government. They are self-employed, they are independent business people,' said Karen Palmer, an adjunct professor at Simon Fraser University. 'The system is publicly funded but privately delivered.'

Bertolini appeared to be confusing single payer with a single-provider system, such as the National Health Service in the United Kingdom, under which doctors and providers work directly for a government entity.

Bertolini is the CEO of a huge for-profit health care insurance company, so one would think we might know the difference between national health insurance and a national health system. The example of Canada is a one often used by those who promote "single-payer" health insurance in the US, an idea which Mr Bertolini opposes. So one would think we would be familiar with the Canadian example.

Summary

It would be too much to expect that health care policy debates would be rigorously evidence-based. However, lately they seem to include loudly expressed views devoid of facts or rationality. We have proposed that this is the result of "managerialism."
We have discussed this doctrine, promoted in business schools that people
trained in management should lead every type of human organization and
endeavor. Management by people from the disciplines most relevant to
the mission and nature of particular organizations should be eschewed.
So managers, not physicians or other health care professionals, should
lead health care organizations. Following that theme, managers, or
those like them, rather than health care professionals and health policy
experts should lead health policy.

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives
that often put short-term revenue ahead of the health of patients and
the population.) And in the latest health care reform debate, some of
the politicians and political appointees who are the de facto managers
of health policy have
disdained the advice of health care professionals and health policy
experts. (And above we presented an example of a true managerialist corporate health care executive who also - to put it bluntly - did not seem to know what he was talking about in a discussion of various country's health insurance systems.)

Ignorance and falsehood in the health care debate could also be part of a broader trend toward anti-intelletualism or what has recently been termed "The Death of Expertise" (see this New York Times review of a book with that title.) Managerialism could be part of that trend. And the extreme relativism of post-modernism, which we also discussed in the context of the current debate on health care reform, could be another.

Facts, however, are stubborn things. Evidence is evidence, no matter
what politicians or corporate executives it might offend. Basing legislation on the sorts of
alternative thinking displayed in the cases above could lead to real
life, or life and death consequences for the sick, injured and
vulnerable. True health care reform requires clear thinking and the
input of people who actually know something about health care.

Sunday, September 17, 2017

On Health Care Renewal we discus the dark side of health care, particularly of the leadership and governance of health care, that has enabled health care dysfunction. Our discussions are based on publicly available information, often produced by dogged health care journalism.

Uur work has become more difficult as journalism is challenged by economic circumstances. Yet now there are worse threats. Despite First Amendment protections of freedom of speech and the press, journalism is now under fire from the highest reaches of US government.

Information Blockade at the Department of Health and Human Services

Two recent articles in the Columbia Review of Journalism pointed to specific problems The first, "Under Trump, Health Reporters Confront an Information Blockade," September 7, 2017, focused on decreasing transparency at the US Department of Health and Human Services (DHHS), and its Center for Medicare and Medicaid Services (CMS). It provided numerous examples of officials failing to respond to apparently straightforward requests for legitimate health care information. For example,

Washington Post healthcare reporter Paige Winfield Cunningham recently raised a few serious questions about how the Trump administration planned to manage Obamacare’s fall enrollment season. 'The six-week sign-up period will be the first handled exclusively by an administration that’s hostile to the Affordable Care Act,' Cunningham wrote, 'and one that hoped by now to see Congress pass legislation unraveling much of the law.'

Any reporter might have asked the questions Cunningham put to the Department of Health and Human Services, some of which she published in her daily Health 202 column:

Will the government contact current enrollees to alert them that sign-ups will last just 45 days, about half as long as in the past three years? Will HHS run call centers for consumers who need help as they look for plans? Will the HealthCare.gov computer system be adjusted to accommodate a possible crush of shoppers given the shorter sign-up period? And how will automatic enrollment be handled?

HHS offered no answers, although a spokesperson for the department’s communications staff did provide Cunningham with a statement: 'As open enrollment approaches, we are evaluating how best to serve the American people who access coverage on HealthCare.gov.' Even that statement did not stand for long, reported Cunningham:

An hour later, the spokeswoman, Jane Norris, requested that the statement be withdrawn, saying that she did not have permission to release it. When I asked her again for detailed answers, neither she nor anyone else at HHS responded further.

'Nobody at HHS ever reaches out to me,' Cunningham told CJR during an interview.

Also,

Matt Wynn, data reporter for MedPage Today, went public with his troubles prying loose the data underlying a series of maps CMS sent out this summer. One map published in early June identified counties without insurers selling policies on healthcare.gov this fall, and a news release announced at least 35,000 active Exchange participants live in counties projected to be without coverage in 2018.' Wynn asked CMS to see the numbers supporting those conclusions.

I shot an email to the media relations office in the department, asking for the data behind the map.

About an hour later I got a response. No further information would be shared at this time, wrote Shelby Venson-Smith, a public affairs specialist. Adding insult to injury, the non-response was not to be used as a direct quote, the email said.

However, while DHHS and CMS officials resisted responding to uncomplicated requests for information,

they seem to have plenty to say in their news releases and email blasts, which disparage the health law and sound more like campaign propaganda and GOP talking points than routine communications from a federal agency. The Obama administration was not shy about using the same PR tools to boost the ACA. But messages from HHS now feel substantively different, perhaps because they are aimed at denigrating a law they have a legal responsibility to administer.

Thus officials at DHHS seem to now be more interested in following the party line of the current administration than in providing basic information to the public.

Many other health care journalists experienced similar problems, including Charles Ornstein from ProPublica, Dan Diamond of Politico, Harris Meyer of Modern Healthcare, and Noam Levy of the Los Angeles Times.

Trudy Lieberman, the author of the CJR article, wrote,

HHS and CMS are powerful agencies that could decide the future of critical programs like Medicaid and Medicare, the Obamacare insurance marketplaces, and whether or not hospitals are considered safe. But when agency press officials avoid interviews and refuse to answer questions, it’s hard to present their positions fairly and understand whose side they are on. Government agencies are supposed to be objective about industry practices under their jurisdiction. But if reporters cannot get honest information about the industries they regulate, where can they go?

Kathryn Foxhall, who "works with the Society of Professional Journalists on freedom of information issues," put it this way,

I don't see the administration ever stopping what they are doing, unless we as journalists pull out all stops and call it the censorship that it is.

Public Health Without Public Information?

Worse, one week later, CJR published another article on the US Centers for Disease Control (CDC). The CDC is the lead US public health agency.

Axios published text from a late August email by a CDC public affairs officer that directs staff to route any correspondence with journalists—'everything from formal interview requests to the most basic of data requests'—through the communication office at its Atlanta headquarters:

'The message—sent by public affairs officer Jeffrey Lancashire and dated Aug. 31—instructs all CDC employees not to speak to reporters, ‘even for a simple data-related question’… Lancashire did not respond to requests for comment about the policy. But I’d love to know what harm was being done by CDC employees answering ‘the most basic of data requests.’'

Thus CDC officials now seem to want to substitute public relations for straightforward information provision. Given that the mission of CDC is public health, this seems to be an example of mission-hostile management, a concept we have used most often to refer to the management of private health care organizations, not US government agencies. Charles Ornstein of ProPublica commented

This is genuinely disturbing. The idea that someone at CDC headquarters needs to sign off on responses to basic data requests shows a level of media control beyond which I have ever seen. What’s next?

Felice Freyer of the Boston Globe tweeted

CDC is employed by taxpayers. Why shouldn't its work be readily shared with them?

At Health Care Renewal, we have often discussed the anechoic effect, a taboo against public discussion of many aspects of health care dysfunction, particularly those that might discomfit people who are personally profiting from the current system. In particular, the currently dysfunctional health care system has made the leaders of big health organizations, particularly for-profit corporations, hugely wealthy. Furthermore, big health care organizations have been eager to develop financial relationships with health care professionals, academics, leaders of non-profit organizations and NGOs, etc, leading to a web of conflicts of interest draped over health care. Who wants to speak out when doing so may offend not only distant CEOs, but also one's colleagues, bosses, friends, relatives etc who may have financial ties to those CEOs' corporations? Furthermore, who wants to speak out when large corporations command huge marketing and public relations operations that can be used to drown out unwanted ideas, and legal departments ready to threaten litigation?

Now government health care officials seem to be enlarging their own public relations efforts while shutting off access of honest information. This will only make open discussion of the true causes of health care dysfunction more difficult.

Even more chilling is the threat that health care officials now may be attempting actual censorship. We have depended on health care journalists to root out bad behaviors that lead to health care dysfunction, and by doing break taboos about discussion such behaviors. Up to now we have assumed at least that government would not make it harder for journalists to do their job, protected by the Bill of Rights protections of free speech and a free press. But now the current administration seems to be taking the side of censorship.

From Censoship to Incitement of Violence?

Even worse, some worry that the regime's hostility to journalists threatens their actual harm. In early September, the New York Times reported on comments by the United Nations High Commissioner for Human Rights, who

was reacting to Mr. Trump’s recent comments at a rally in Phoenix during which he spoke of 'crooked media deceptions' in reports of the violent clashes at a white nationalist rally in Charlottesville, Va., that resulted in the death of a counterprotester.

In Phoenix, the president’s words also appeared to whip up audience hostility toward journalists.

The failing @nytimes writes false story after false story about me. They don't even call to verify the facts of a story. A Fake News Joke!
— Donald J. Trump (@realDonaldTrump) June 28, 2017

'It’s really quite amazing when you think that freedom of the press, not only a cornerstone of the Constitution but very much something the United States defended over the years, is now itself under attack from the president himself,' [UN official] Mr. al-Hussein said. 'It’s a stunning turnaround.'

Furthermore,

'To call these news organizations fake does tremendous damage,' Mr. al-Hussein added. 'I believe it could amount to incitement. At an enormous rally, referring to journalists as very, very bad people — you don’t have to stretch the imagination to see then what could happen to journalists.'

Ominously, the response from the White House included more unsubstantiated charges of "false narratives," and threatened media tha fails to be responsible as judged by the regime, never mind the First Amendment and its promise of free speech and a free press.

the White House press secretary, Sarah Huckabee Sanders, said in an emailed statement, 'We believe in free press and think it is an important part of our democracy, but the press also has a big responsibility to the American people to be truthful. Their job is to report the news, not create it.

'Is it not ‘dangerous’ for the media,' she continued, 'to create false narratives and overzealous attacks against the president that the American people chose to be their leader? The president is focused on growing our economy, creating jobs, securing our border and protecting Americans. Since those are also the priorities of most Americans, hopefully the media will make covering them theirs.'

Strong, even overzealous verbal and written attacks on politicians, the president included, have been essential parts of American democracy since the Bill of Rights was ratified. The First Amendment shows that our political system values such boisterous discourse. The White House press secretary thus threatened not only the press but the fundamental US system of government.

Strategic Hostility

Finally, there is an argument that the regime's attacks on the media may not be just reckless, but strategic and calculated. The UN Special Rapporteur on the promotion and protection of the right of freedom of opinion and expression, Prof David Kaye of University of California - Irvine School of Law, wrote,

The President’s attacks may be reckless – who knows whether someone in his audience will take the President’s word as license to take action against enemies of the American people? – but they are not without purpose. They have concrete aims: to intimidate reporters into certain kinds of coverage, or clarify for his favored outlets what coverage he desires, or plant the seeds of doubt about news stories (such as the Russia investigation led by Robert Mueller).

Also,

However, when we tie together the jeremiads and rhetoric with what the Trump administration is doing in other governing spaces, the practice of attacking the press becomes clearer as policy than solely reckless rant.

First, the attack on the press is not merely rhetorical; it is increasingly reflected in policy.

And,

Second, Trump’s incendiary statements work in tandem with a pattern of lying and disinformation, both aiming to limit the accessibility of truthful information.

And,

Third, the administration operates as if it has something to hide.

Who knows what they might be hiding. But there certainly have been plenty of accusations of severe conflicts of interest and corruption affecting the Trump presidency?

Summary

Up to last year, I was cautiously optimistic that the anechoic effect was starting to erode, enabling the health care discussion to begin to encompass the deeper causes of health care dysfunction. Since November, however, we seem to be going backward. What little openness and transparency that were developing are at risk of sinking under a new tide of propaganda and censorship. My concerns have primarily been about health care and health care dysfunction, but the larger trends threaten our whole society and the ability of the US to maintain itself as a republic. Ben Franklin's warning becomes more acute. What we have is only

Thursday, September 07, 2017

An article just published online(1), and reported so far in only one major media outlet (the Guardian, based in the UK) showed how hookworm, now considered a disease of poor, third world countries, has returned to the American south. This in a country which spends more per capita on health care than any other supposedly developed country.

Background - the Supposed Eradication of Hookworm

A 2009 article in Health Affairs documented the supposed elimination of common diseases once found in US.(2) The background of the article included:

In 1916 a new textbook appeared on the 'endemic diseases of the southern states.' With chapters on malaria, pellagra, and intestinal worms, the book’s authors identified the region as particularly, and peculiarly, diseased. Absent was the dominant southern disease of the nineteenth century: yellow fever. Although yellow fever had traveled hand in hand with the import trade of southern cities, the twentieth-century triad of pellagra, malaria, and hookworm was inextricably linked with the rural poverty engendered by cotton culture and the tenant labor system that evolved to replace slavery after the Civil War. The rural farm worker had little money or access to health care, ate a poor diet, and lived in a subtropical landscape that was host to parasitic worms and mosquitoes. In 1916 the South’s endemic diseases appeared to be thoroughly entrenched. Later, in the depths of the Great Depression, these diseases continued to plague southerners. Yet by 1950 southerners were almost free of them all.

The article noted that hookworm in particular was associated with the South:

Hookworm disease was once associated so much with the South that when a baseball commentator referred to southern players as coming from the 'Hookworm Belt' in 1947, the phrase needed no explanation. The hookworm is a tiny parasite that latches onto the wall of the small intestine, secretes an anticoagulant to promote bleeding, and feeds on the host’s blood. About 110 worms can consume a teaspoon of blood a day. A well-fed host with adequate iron intake can usually replace the lost iron and plasma proteins of a mild infection, but a malnourished person harboring sizable numbers of parasites will become anemic and protein deficient. In children the disease stunted physical and cognitive development. It made them weak, apathetic, and perpetually tired.

In the beginning of the 20th century, the Rockefeller Foundation launched a campaign that probably began the apparent eradication of hookworm.

In 1902, however, Charles Stiles, a medical zoologist, recognized in southerners the same symptoms he had seen among European hookworm victims. Once he started looking, he found a startling prevalence of the disease. He convinced representatives of the Rockefeller Foundation to take up the cause of hookworm eradication, and in 1909 the philanthropy launched an all-out assault on the disease. Their initial surveys found 43 percent of those surveyed to be infected with hookworm; in some areas the percentage rose into the 90s.

The Rockefeller campaign stressed education, treatment, and the assumption by local and state boards of health of the responsibility to carry on what the foundation had begun. With a million dollars in their coffers, the Rockefeller men spread across the South, offering lantern shows about the hookworm, testing and treating individuals, and pushing the construction of sanitary privies. Surveys of rural schools and churches found that 80 percent lacked any sort of privy; private homes were even less likely to have sanitary facilities. Children of all classes went barefoot in the summer, often not wearing shoes until they were teenagers. By 1914, when Rockefeller ended its U.S. campaign, the prevalence of infection had been cut to 39 percent, but the message of hookworm and its implications was now well known throughout the South. The campaign also energized southern public health, leaving a legacy of empowered institutions on the state and local levels.

For more on the history of the Rockefeller Foundation campaign, look here. I hope the Foundation will not mind me using a picture of a hookworm treatment clinic from 1923.

Hookworm persisted for a surprisingly long time after these initial eradication efforts, although it seemed to be nearly gone by the 1980s. The article noted that

Even in the 1960s there was persistent infection in coastal South Carolina (3 percent) and eastern Kentucky (14 percent). One source reported that hookworm prevalence in southern Georgia went from 60 percent in 1910 to 13 percent in 1964 and to 6 percent in 1970.

So the disease prevalence fell from over 40% in the early 20th century to a few percent by the 1980s. One particular mechanism for the decrease was basically better plumbing.

Concerns about typhoid, which was frequently fatal, drove the cities to put in sewers and running water, and fears that the privies of the poor would infect the affluent meant that even the poorer sections of towns had sanitary waste disposal throughout much of South in the 1920s. Slowly the expectation grew that the sanitary privy was essential for adequate housing. In North Carolina in the 1940s, the state board of health required them by law.

So the problem appeared to be solved. I learned about hookworm in a course in tropical diseases in medical school in the 1970s. At the time, since I was not planning to go into global health, the knowledge did not seem very relevent. I suspect that such courses were no longer very prevalent in medical school.

That was then. This is now.

Hookworm Returns to the Impoverished US South

The new article by McKenna et al noted that hookworm is still very common globally. In addition, it noted that the conditions are again ripe for the return of hookworm, and presumably other ailments now considered irrelevant to developed countries, to parts of the US. In particular, the advances in plumbing so important to the eradication of hookworm are no longer so much in evidence.

According to the Alabama Center for Rural Enterprise (ACRE), an organization that addresses poverty and economic development in one of the poorest areas of the nation, there continues to be residences without adequate sanitation systems, increasing exposure to open sewage near dwellings. The “Black-Belt” soil native to this area is composed of a firm sedimentary limestone bed overlain with a layer of dark, rich soils, which requires expensive septic systems for proper waste disposal. In Lowndes County, Alabama, where the per capita income is $18,046, and 31.4% of the population lives below the poverty line, sanitation systems are unaffordable. For rural, impoverished individuals, the main form of waste removal involves use of 'straight piping,' a method involving a series of ditches or crudely constructed piping systems to guide human waste away from the residence. Most pipes never reach more than 10 meters in length, and during rainstorms or flooding, the residents report visible stool entering their homes (reported by ACRE, unpublished data).

The investigators therefore performed an epidemiological study in Lowndes County. There sample size was small. However, their findings were striking. More than one-third (34.%) of subjects tested positive for necator americanus, the American hookworm. This is close to the prevalence reported back in the early twentieth century.

The Guardian article provided vivid anecdotal evidence about the state of public health in rural Alabama that likely contributed to this result. The reporter's tour of Lowndes county revealed vividly inadequate sewage systems. He documented that in Alabama, "public health" was ostensibly insured by making it a criminal offense for people to have inadequate sewage systems.

people were afraid to report the problems, given the spate of criminal prosecutions that were launched by Alabama state between 2002 and 2008 against residents who were open-piping sewage from their homes, unable to afford proper treatment systems. One grandmother was jailed over a weekend for failing to buy a septic tank that cost more than her entire annual income.

'People are scared. They don’t like to speak out as they’re worried the health department will come round and cause trouble,' [community activist Aaron] Thigpen said.

Apparently the state government does not see that it has any resonsibility to provide adequate sewer systems, or provide any help to people to improve sanitation, even those clearly unable to affort it on their own. Consider, for example, the plight of Ruby Rudolf

Rudolph, now 66, does have her own septic tank at the back of her house, which she shows us in the sweltering 41C (105F) heat. But it doesn’t function properly and when it rains the tank spills over, spreading raw waste all over the yard. 'That’s better than when it flushes back into the house, and I’ve had that too,' she said.

She’s been told a replacement system would cost her at least $12,000, which is beyond her means. She runs through her finances: she gets up at 4am every day to do an early shift at a Mapco convenience store, which brings in less than $1,200 a month. From that amount she has to pay $611 for her mortgage and there’s the electricity bill that can be more than $300 a month when it’s hot and the air conditioning is busy. There’s not a lot left to put toward a new tank.

Left entirely unsaid in the scholarly article or the Guardian story is the likelihood that any residents of these rural Alabama counties have access to any other ways to mitigate the hookworm problem. Left also unsaid is whether they have access to health care professionals who could test them or treat them for hookworm.

Conclusions

As we have noted endlessly, the US spends more per capita on health care than any other developed country. US politicians used to make the claim that the country has the best health care system in the world, often to ward off any attempts at true health care reform. However, US rankings on various measures - some of which may be disputed - of health care processes and outcomes have been decidedly mediocre. (See for example the latest Commonwealth Fund study here.)

The new study of hookworm prevalence was not based on a big, systematic, or geographically diverse sample. However it is striking, and dismaying that a disease once thought to be eradicated is again alive and well in the poorer parts of a very rich country.

Note that while the eradication of hookworm was partially attributed to the energizing of public health in the south, currently public health officials seem to think their job is to arrest poor people who cannot afford adequate sanitation. The government does not seem to think it has a responsibility to assure working sewers or other forms of basic sanitation. There also seems to be a governmental abandonment of public health focused on reaching individuals who might most be at risk of disease.

Meanwhile, the country, as we have said before, has seen the diversion of tremendous amounts of health care and public health dollars into the pockets of health care managers, their cronies, health care management and administration in general, and in some cases investors. This appears in turn to be a consequence of deregulating the system, allowing concentration of power, allowing the commercialization of various kinds of health care organizations (insurance, hospitals, medical practices, etc), and of turning health care leadership over to managers trained in business schools (managerialism) with no appreciation of health care professionals' values, and with perverse incentives focused on increasing their organizations' revenue and hence their personal enrichment. We can spend untold sums on new treatments with dubious margins of benefits vs harms, but not on basic public health or access to primary care.

Thursday, August 31, 2017

In recent years, as a result of the 2010 IT-related injury and 2011 death of my mother, I have engaged myself as an independent EHR forensic expert regarding evidentiary and patient harm issues in medical malpractice litigation.

Interestingly and disappointingly, I still often find that hospital attitudes towards health IT safety and information transparency have changed little since 2010 or, for that matter, the 1990s when I did my postdoc in medical informatics. Hospitals and defense attorneys often (ab)use the lack of technology experience of judges to delay or prevent evidentiary transparency. I'm thus frequently retained by injured patient's attorneys (or attorneys representing the executors of deceased patients' estates) to help overcome this phenomenon.

In doing so, I can find myself under attack in deposition, even before any proceedings begin.

For instance, I was recently asked in a deposition, as an attack geared towards injuring my credibility, if an assessment of me published in the literature, that I was a "strident critic of electronic health records" was fair.

I replied that it was not a fair assessment, that I was a critic of bad health IT, but juries potentially will hear only the one-liner.

Bad Health IT ("BHIT") is defined as IT that is ill-suited to
purpose, hard to use, unreliable, loses data or provides incorrect data, is
difficult and/or prohibitively expensive to customize to the needs of different
medical specialists and subspecialists, causes cognitive overload, slows rather
than facilitates users, lacks appropriate alerts, creates the need for
hypervigilance (i.e., towards avoiding IT-related mishaps) that increases
stress, is lacking in security, compromises patient privacy or evidentiary fitness, or otherwise
demonstrates suboptimal design and/or implementation.

It appears the attorney attacking me in this manner found the phrase "strident critics of electronic health records" online in a Feb. 18, 2013 Kaiser Health News Article by Jay Hancock (that also appeared in the Philadelphia Inquirer) entitled "Health Technology’s ‘Essential Critic’ Warns Of Medical Mistakes."

That article is at http://khn.org/news/scot-silverstein-health-information-technology/.It is unfortunate that cherry-picking in an attempt to neutralize a proponent of caution and evidentiary fairness in health IT still occurs in 2017. That 2013 article itself centers on my patient safety-centered critique of bad health IT. At the heart of the article is this:

... Silverstein “is an essential critic of the field,” said Dr. George
Lundberg, editor at large for MedPage Today and former editor of the
Journal of the American Medical Association. “It’s too easy for those of
us in medicine to get excessively enthusiastic about things that look
like they’re going to work out really well. Sometimes we go too far and
don’t see the downside of things.”

Computer mistakes voluntarily reported to the Food and Drug Administration include those that researchers said were linked to 44 injuries and six deaths
at unidentified institutions. Those problems included tiny fonts
causing caregivers to click on the wrong medication; flipped images that
led a surgeon to operate on the wrong side of a patient’s head; and
lost or misdated test results that caused unnecessary surgery or delayed
treatment.

I perhaps should have asked counsel if they were a supporter of bad health IT that injures and kills people. If the matter comes up again, I very well might.

I felt sorry for that attorney, however. I was also asked if I still "kept records" on my 1977 Heathkit H8 computer or words to that effect, with a possible implication that maybe I was hiding things on that machine. This is a computer I still have which said attorney must have seen on my web page of technology interests at http://cci.drexel.edu/faculty/ssilverstein/medinformatic1/ham.htm.

I replied to the attorney that I last used the H8 to teach Yale informatics postdoctoral fellows (about computer architecture) in the mid 1990's when I was faculty there, and that it has not been turned on since.

I didn't go into how doing so would require me to carefully clean approximately 500 small tin-plated (a costs saving by Health by not using gold) pins and sockets that connect the daughtercards to the motherboard, and probably replace long-unused power supply electrolytic filter capacitors before even applying power.

My late 1970's Heathkit H8 computer, Intel 8080 CPU @ 2 MHz, 64K RAM

I also was not permitted the time to relate to the counselor that the computer is quite primitive, having 64 kilobytes of RAM, with its main mass storage being special hard-sectored (and now nearly unavailable, as opposed to the more common soft-sectored) single-density, single-sided 5.25" floppy disks, each holding about 80,000 characters of information. 80 kilobytes. By comparison, the common cellphone today has 2,000,000 kilobytes = 2 Gb of built-in storage...

It's sad, but I almost broke out laughing at the bizarre technology-naive question. These are the type of folks who are defending bad health IT and taking advantage of the lack of knowledge of many judges about the technology.

The attorney also for some reason demanded me to affirm that the health IT-related medical malpractice case in which I am substitute plaintiff, that of my late mother, had been dismissed. He didn't ask me the case status, but instead in a declarative manner stated "and that case has been dismissed, is that right?"

God only knows where that misinformation came from. IT industry/defense lawyer Listserv gossip perhaps?

It was my pleasure to inform him that he was entirely incorrect. After many years of delay, pretrial conference is scheduled for early October, and trial sometime after that, regarding a travesty caused by bad health IT and careless clinicians. In a gross medication reconciliation failure, my mother's critical cardiac medication, Sotalol hydrochloride was inexplicably terminated, resulting in cascading problems leading to disaster.

The Trump administration has tapped a former for-profit college official to lead the Education Department unit that polices fraud in higher education.

Julian Schmoke Jr., who previously directed campus operations at West Georgia Technical College and served as a dean at DeVry University, will be the department’s new chief enforcement officer, according to an internal email obtained by POLITICO.

Schmoke will lead the Student Aid Enforcement Unit, which was established by the Obama administration to more aggressively combat fraud and deceptive practices at colleges and universities.

The unit has been without a permanent leader since the departure earlier this year of Robert Kaye, a former top consumer protection attorney at the Federal Trade Commission.

'Julian possesses over 16 years of experience in higher education leadership with extensive knowledge in the development and implementation of strategies for achieving student success, higher education policy and evaluation of academic programs,' the head of the Federal Student Aid Office A. Wayne Johnson wrote in an internal email last week.

Dr Schmoke's Work for DeVry University, and its Previous Fraud Settlements

Left unsaid by Department of Education officals was that Dr Schmoke had a significant role in DeVry University. However, per Politico

Schmoke worked in various roles at DeVry University between October 2008 and April 2012, including as an associate program dean, according to his LinkedIn page.

DeVry’s parent company, which has since rebranded as Adtalem Global Education, last year agreed to pay $100 million to resolve allegations by the Federal Trade Commission that the for-profit college company misled students about their job and salary prospects.

The company also separately reached a settlement with the Education Department over similar allegations. Obama administration officials cited those cases against DeVry as they announced the formation of the Student Aid Unit last year.

The unit Schmoke will oversee is also responsible for processing debt relief claims filed by federal student loan borrowers who say they’ve been defrauded by their college. DeVry students had 1,872 'borrower defense to repayment' claims pending before the department, according to a July 7 letter from acting Undersecretary of Education James Manning.

In December, the Federal Trade Commission announced a $100 million settlement with DeVry Education Group, parent of DeVry University. Under the settlement, DeVry will pay $49.4 million in cash to be distributed to qualifying students who were harmed by the deceptive ads, as well as $50.6 million in debt relief. The debt being forgiven includes the full balance owed —$30.35 million— on all private unpaid student loans that DeVry issued to undergraduates between September 2008 and September 2015, and $20.25 million in student debts for items such as tuition, books and lab fees, according to the FTC.

While Dr Schmoke had left DeVry by the time the settlement was made, he was there at the time DeVry was taking the actions that led to the lawsuits. Per the Wonkette blog,

Dr. Schmoke was a dean at DeVry between 2009 and 2012. During that time, the Federal Trade Commission sued the school for claiming that 90% of its graduates were employed in their field within six months of graduation. In fact, the real number dipped as low as 52%. Per WaPo,

According to the FTC lawsuit, DeVry counted graduates as working in their field when they were not, in order to boost its employment outcomes. A 2012 graduate who majored in business administration was working as a server at a restaurant, while another with a degree in technical management was working as a rural mail carrier.

Yet the creation of the unit of the Department of Education that Dr Schmoke is going to lead seems to have been inspired by the sorts of abuses that his former company, DeVry, was alleged to have committed, (see report by National Public Radio in 2016).

Thus, as an opinion piece in the Atlantic asserted, the appointment of Dr Schmoke "provoked complaints from critics who pointed out that DeVry recently
settled several claims brought against it by regulators alleging it had
engaged in some of the very abuses the unit is charged with eliminating." A writer for Gizmodo put it more bluntly,

the new student protection bureau of the federal government just hired a
guy who worked at the same company whose malicious practices inspired the creation of that new student protection bureau. It’s like hiring one of Al Capone’s henchman to run the FBI!

Of course, the appointment was made by an administration headed by the man for whom Trump University was named, the same bogus university which also settled fraud allegations (see the New York Times story from November, 2016 here, and our post here).

The issue is no longer laxity or timidity in the protection of the public from fraud and deception. The issue seems to be that the fraudsters are now to be in charge of the public's protection. This has dire implications for the country.

Discussion - Implications for Off-Shore Medical Education

But we are focused on health care dysfunction, and this particular case also seems to have dire implications for medical eduction.

Admission to US medical schools is increasingly difficult. So many who
seek medical careers may be tempted to apply to schools outside the US.
In the last 30 years, American entrepreneurs have opened offshore
medical schools, mostly in the Caribbean, that cater to US students.
They teach in English, and do not require immersion in an unfamiliar
culture, so may be more attractive than medical schools in other
countries whose mission is to educate physicians to practice in those
countries. In 2010, Eckhert documented that the number of offshore
medical schools,
"for-profit institutions whose purpose is to train U.S. and Canadian
students who intend to return home to practice," but not to train
physicians to practice in the countries in which these schools are
located, was rapidly growing.(Eckhert NL. Private schools of the Caribbean: outsourcing medical education. Acad Med 2010; 85: 622-630. Link here.) By 2010, there were 33 such schools,
20 of which were new since 2000.

Such offshore medical schools exist in a grey area. The small countries
or colonies in which they are located usually do not seek to regulate
them, since the physicians they produce are going to practice elsewhere.
There is no requirement that these offshore medical schools be
accredited in the US. Such accreditation is currently not required for
individual graduates
of such schools to be admitted to US house-staff programs or
for US licensure. So perhaps it is not surprising that little is known
about these schools.

How they choose students, the qualifications or even names of their
faculty, their curriculum, how they supervise clinical training (which
is mostly done by affiliated North American hospitals), and what happens
to their graduates are obscure. Eckhert attempted to describe what is
known, but noted 'variability exists in the availability of information
on faculty; where data exists, it is noted that most of the permanent
on-site basic science faculty are internationally trained, many have no
documented medical education experience in the United States, and it is
not uncommon for them to be OMS [offshore medical school] alumni.'

Since I wrote that, several anecdotes about life as an off-shore medical student have appeared (in February, 2017, and in March, 2017, in KevinMD). Both stressed that the modus operandi of these schools is to have relatively lax entry criteria, make a lot of money from the tuition of the students initially enrolled, and then ruthlessly weed out the weakest, who may nonetheless be left with tremendous debt. Furthermore, the March, 2017 post noted further signs of poor quality, including "mandatory lectures are nearly pathetic. There are so many mistakes made by the inexperienced professors, and the lecture becomes confusing and muddled." Further, students who have any "emotional distress/burnout/sickness" are left to sink or swim, as the "staff is disconnected and said either repeat the term after you seek medical attention or just quit."

Given that there are no widely accepted ways to measure the quality of medical schools, there are thus even more reasons to worry about the quality of the education received in off-shore medical schools than in US and Canadian schools.

Things are likely to get much worse, though, if those in charge of US government agencies that are supposed to protect the public in general, and patients' and the public's health in particular are run by people who previously were involved in predations upon the public.

It seems silly for me to go on about true health care reform at a time when crooks can be recruited into the police department.

Thursday, August 24, 2017

Stealthy, deceptive systematic marketing, lobbying, and policy advocacy campaigns on behalf of big health care organizations, often pharmaceutical, biotechnology and medical device companies, have long been a subject of Health Care Renewal. A relatively recently revealed example was the stealth marketing campaign used by GlaxoSmithKline to sell its antidepressant Paxil. This campaign included manipulating and suppressing clinical research, bribing physicians to prescribe the drug, use of key opinion leaders as disguised marketers, and manipulation of continuing medical education. Other notable examples included Johnson and Johnson's campaign to sell Respirdal (look here), and the infamous Pfizer campaign to sell Neurontin (look here and here). Notably, stealth marketing seemed to be one reason for the growing popularity of narcotics (opioids) starting in the 1990s (look here).

Prof Tomas Philipson Named to President's Council of Economic Advisors

This week this report suddnely appears very salient, since Yahoo News just revealed that a top leader of Precision Health Economics, Prof Tomas Philipson, has been nominated to the President's Council of Economic Advisors by Donald Trump.

Last Monday, the White House confirmed that Tomas J. Philipson, a health care economist, was joining the President’s Council of Economic Advisors.

That announcement was made just hours after Trump publicly accused Merck CEO Kenneth Frazier of charging patients 'ripoff prices' for drugs after he resigned from the President’s Manufacturing Council in protest at the president’s response to the violence at a white nationalist rally in Charlottesville, Virginia last weekend.

Now that Ken Frazier of Merck Pharma has resigned from President's Manufacturing Council,he will have more time to LOWER RIPOFF DRUG PRICES!

Given the potential influence of Prof Philipson on the Council of Economic Advisors, it is worth summarizing what ProPublic said about his career at Precision Health Economics.

PHE as Orchestrator of Stealth Marketing and Policy Advocacy

First, the business of PHE is to help pharmaceutical and biotechnology companies market their products and influence public policy in their favor.

While collaboration between higher education and industry is hardly unusual, the professors at Precision Health Economics have taken it to the next level, sharpening the conflicts between their scholarly and commercial roles, which they don’t always disclose. Their activities illustrate the growing influence of academics-for-hire in shaping the national debate on issues from climate change to antitrust policy, which ultimately affect the quality of life and the household budgets of ordinary Americans — including what they pay for critical medications.

Furthermore,

'This is just an extension of the way that the drug industry has been
involved in every phase of medical education and medical research,'
said Harvard Medical School professor Eric G. Campbell, who studies
medical conflicts of interest. 'They are using this group of economists
it appears to provide data in high-profile journals to have a positive
impact on policy.'

The firm participates in many aspects of a drug’s launch, both
advising on 'pricing strategies' and then demonstrating the value of a
drug once it comes on the market, according to its brochure. 'Led by professors at elite research universities,' the group boasts of
a range of valuable services it has delivered to clients, including
generating 'academic publications in the world’s leading research
journals' and helping to lead 'formal public debates in prestigious,
closely watched forums.'

Again, some people may naively imagine that academic publications are written by unbiased academics, not hired guns for industry, and that formal debates on major issues ought to again by led by people who are disintered and authoritative, not hired guns. That would be very naive.

So PHE has set itself up as a vehicle to market and advocate on behalf of big corporations while making that work appear to be unbaised academic discourse. In particular,

Note that many of these companies are known for perpetrating the kinds of marketing shenanigans that we discuss on this blog. See the links above.

PHE Has Been Accused of Biased Work for Pharma Prettied by Its Principals' Academic Credentials

To justify the value of expensive drugs, the professors affiliated with
Precision Health Economics rely on complicated economic models that
purport to quantify the net social benefits that the drugs will create.

However,

Critics have at times questioned the assumptions underlying the
consultants’ economic models, such as the choice of patient populations,
and suggested that some of their findings tilt toward their industry
clients. For example, some have tried and failed to reproduce their
results justifying the value of cancer treatments.

Precision Health Economics allows drugmakers to review articles by
its academics prior to publication in academic journals, said a former
business development manager of the consulting group. Such prior review
is controversial in higher education because it can be seen as impinging
on academic freedom.

In addition,

About 75 percent of publications by the firm’s employees in the past
three years have either been funded by the pharmaceutical industry or
have been done in collaboration with drug companies, a ProPublica review
found.

Some academics worry that a tight relationship with industry might
suggest bias. 'I personally find, when your enterprise relies so
substantially on a particular source of funds, you will tend to favor
that source,' said Princeton economist Uwe Reinhardt.

Thus several of the firm's campaigns have produced considerable controversy. For example,

Advocating Increased Pricing for Oncology Drugs

Precision Health Economics raised its profile in 2013 when the president’s annual economic report cited
a cancer study by several of the firm’s principals and consultants. To
some critics, though, the study showed how industry funding can taint
academic research.

As the study acknowledged, it was funded by Bristol-Myers Squibb, a company that at the time was developing a much-anticipated cancer treatment. It was priced at more than $150,000
per year when it eventually came on the market. All three founders of
Precision Health Economics were listed as authors of the Health Affairs
article, alongside one of their employees, yet none of the founders
disclosed their ties to their consulting firm in the published study. In
an interview, Goldman said this might have been an 'oversight.'

In addition,

As the cancer study gained national recognition, its methodology and
findings came under fire. Researchers from Dartmouth College tried and
failed to reproduce the results. Cancer care in the U.S., their research found, may actually provide less value than cancer care in Europe, considering cost.

'We know that [the U.S. health care system] is more disorganized and
disorganization is more expensive, so it’s surprising to believe that
the U.S. would perform better in a cost-effectiveness sense,' said Samir
Soneji, one of the authors of the counter-study and an assistant
professor of health policy at Dartmouth. The science in the original
study, Soneji says, was 'questionable.'

Soneji was not alone in his criticism. Aaron Carroll, a pediatrics
professor at the Indiana University School of Medicine, reviewed the
methodology and concluded that the Precision Health Economics
researchers had used a measure that can frequently be misinterpreted.
Instead of relying on mortality rates, which factor in a patient’s age
of death, the study employed survival rates, looking at how long people
live after diagnosis. Cancer screening, which can increase survival
rates, is more frequent for some cancers in the U.S. than in other
countries, Carroll says.

'When they wrote that paper using survival rates, they were clearly
cherry picking,' Carroll told ProPublica. 'If the arguments are flawed
and people keep using them, I would be concerned that they have some
other motive.'

PHE Work on Behalf of PCSK9 Inhibitors

Not long after the controversy over its cancer research, Precision
Health Economics became embroiled in another academic spat related to a
client’s product. This time, it was over a breakthrough treatment that,
injected one to two times per month, could help millions of Americans
with high cholesterol. At the $14,000-per-year price set by one of its
makers, Amgen, the PCSK9 inhibitor could also hike the nation’s annual
prescription drug costs by an unprecedented $125 billion, or 38 percent.
Its price in the U.S. is twice as much as in the U.K.

The U.S. price of the drug has come under vigorous attack from the
nonprofit Institute for Clinical and Economic Review. ICER, which began
as a small research project at Harvard Medical School, studies the
cost-effectiveness of drugs, balancing their value to patients against
the impact of their cost on society. The Centers for Medicare and
Medicaid Services proposed a new rule in March 2016 that includes the
use of value-based pricing studies, specifically citing the work of ICER.

The industry has attacked many of the institute’s studies, particularly those that find a treatment is overpriced.

PHE orchesterated an attack on the ICER conclusions.

ICER concluded
in 2015 that the new cholesterol treatment, the PCSK9 inhibitor, should
cost about one-fifth what Amgen is charging. A few months later,
Philipson, the Precision Health Economics co-founder, and Jena wrote an
op-ed in Forbes, citing the institute’s research and deriding its
approach to value pricing as 'pseudo-science and voodoo economics.'
Only Philipson disclosed his ties to Precision Health Economics, and
neither academic disclosed that Amgen was a client of the firm.

PHE Principals Have Failed to Disclose Their Conflicts of Interest

The professors’ disclosure of their ties to the firm and to the
pharmaceutical industry in scholarly articles is inconsistent: sometimes
extensive, sometimes scanty. Members of Precision Health tend to reveal
less about their paid work in blogs, public forums like conferences, and legislative testimony.
At the Capitol Hill briefing last May on hepatitis C drugs, Lakdawalla
didn’t mention his affiliation with Precision Health Economics, though
it was listed in the journal issue, which was provided to attendees.

One can argue that failing to disclose relevant conflicts of interest is deceptive.

Prof Philipson's Role in PHE has Increased in Scope

PHE was sold in 2015 to a "privately held biotech company, Precision for Value." Since the sale, "Philipson is listed as chief economist and the chair of the strategy and innovation board."

A Problem Beyond the Revolving Door

We have frequently railed about the revolving door affecting health care. Prof Philipson clearly will be transiting the revolving door, in that he will be going directly from a responsible corporate position into a government role in which we will be able to influence policy that affects the corporation in question (as well as other corporate interests, of course). Nowadays, people frequently transit the revolving door from or to US government positions. We most recently posted about the revolving door affecting health care in the current US administration here.

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry
to the Trump administration once again suggests how the revolving door
may enable certain of those
with private vested interests to have excess influence, way beyond that
of ordinary citizens, on how the government works, and that the country
is
still increasingly being run by a cozy group of insiders with ties to
both
government and industry. The latest cohort of revolving door transits
suggests that regulatory capture is likely to become much worse in the near future.

So, as we have said before.... The continuing egregiousness of the revolving door in health care shows
how health care leadership can play mutually beneficial games,
regardless of the their effects on patients' and the public's health.
Once again, true health care reform would cut the ties between
government and corporate leaders and their cronies that have lead to government of, for
and by corporate executives rather than the people at large.

However, the case of Prof Philipson raises issues beyond the revolving door. Prof Philipson is not a mere corporate executive. He is a master of stealth marketing/ lobbying advocacy. Stealth marketing, in particular, has been one of the scourges of US health care.

Back in a 2006 blog post about the stealth marketing of Neurontin, I wrote:

Physicians must be increasingly skeptical about educational and
scholarly activities that may be disguised efforts at drug marketing.

Shame on the companies that have implemented such stealth marketing
programs. Shame on the academic physicians who have taken money to help
them out without revealing their financial interests to their physicians
colleagues.

This unfortunately is another blow to the current paradigm of
evidence-based medicine. The EBM paradigm calls for physicians to make
optimal decisions for individual patients based on their knowledge of
the clinical context, the patients' values and wishes, and a critical
review of the best relevant evidence from clinical research. For the
paradigm to work, the assumptions are that all relevant research can be
found, and that the research studies, while imperfect, were not
intentionally designed or reported to deceive the reader. Yet the case
of gabapentin adds to fears that relevant evidence that is unfavorable
to the interests of the drug, device, or biotechnology company which
sponsored the work is likely to be suppressed by that sponsor, and that
commercially sponsored research is often deliberately manipulated to
make its results appear more favorable.

Also, as Professor
Dickersin noted (reported by the WSJ), "in exchange for being
experimented upon in trials, patients are told they are contributing to
human knowledge. To withhold negative results from the public breaks
that ethical obligation to such patients...."

I began to think in the years after 2008 that the increasing exposure of stealth marketing (and related stealth lobbying and policy advocacy) campaigns would lead to their eventual decrease. Never in my wildest dreams in 2008 did I foresee a stealth marketing master transiting the revolving door to be appointed to the President's Council of Economic Advisors. (But then again, back then I would have laughed out loud at the notion of Donald Trump as President). I seem to be really bad at prophecy.

We are slipping farther and farther from my ideal of true health care reform.

Sunday, August 20, 2017

Leaders of big health care organizations have long made excuses for rampant conflicts of interest in health care. Usually, their rationales included something about the need to collaborate with industry to spark innovation. However, some leaders may have been directly benefiting from such conflicts (e.g., academic leaders on the payrolls of drug, device and biotechnology firms, even on the firms' boards). Others may not have been, but were making millions in the current system, so why rock the boat? Meanwhile, the risks these conflicts posed of health care corruption were not a subject of polite conversation.

Thus it is no surprise that health care leaders are very resistant to suggestions they reduce conflicts of interest affecting their organization. There was just a recent dramatic case of what it currently may take to break health care leaders from their conflict of interest habbit.

The 2017 Mar a Lago Fundraising Events

It had long been a tradition for some non-profit health care organizations to hold gala fundraisers in Palm Beach, Florida at the Trump Organization's Mar a Lago club. This was not remarkable when Mr Trump was a private citizen. However, when he was elected President, but refused to divest himself of his ownership of the Trump Organization, these fundraisers suddenly looked like conflicts of interest, and possible corruption. Large health care organizations, particularly hospital systems, but also disease advocacy groups, may daily interact with the executive branch of the US government, and may have interests in these interactions going in certain directions. The acceptance by the President, the leader of the executive branch, of money from such organizations, even if in the form of payments to the family company he owns, clearly creates a conflict of interest. If the payments are meant to or to create an impetus for the President to act in favor of the interests of the paying organization could be corruption (abuse of entrusted power for private gain).

Regardless of such ethical concerns, the health care organizations that used Mar a Lago for fundraising were happy to continue their traditions. For example, the Cleveland Clinic persisted in holding its fundraiser there despite protests by its own students, health care professionals, and patients' families, many of whom were particularly irate because of Mr Trump's attempt to ban travel to the US by Muslims, which had already prevented on Clinic physician from re-entering the US (look here). Also, the Dana-Farber Cancer Institute similarly persisted despite similar protests (look here). In neither case did the leaders of the two clinical institutions deign to even discuss the issues of conflicts of interest, or corruption.

Concerns about Next Year's Fundraising Events

On August 4, the Chronicle of Philanthropy summarized the issues. In general, it seemed that the monetary returns of holding events at Mar a Lago trumped any puny concerns about conflicts of interest:

Fundraisers say Palm Beach events are among the most lucrative they hold and provide an opportunity to court donors who have the potential to give big sums long after the galas are over.

Mar-a-Lago offers more space than any other venue in the area, increasing the opportunity to attract more donors.

So,

A Chronicle analysis of permit data shows how lucrative events at Mar-a-Lago can be.

In 2016, when Mr. Trump’s unorthodox and often controversial presidential campaign was in full swing, the Cleveland Clinic raised $963,029, after expenses, at an annual ball; Susan G. Komen brought in $700,00 at its 2016 Mar-a-Lago event, and the Palm Beach Police Foundation raised $643,975.

More qualitatively,

For many charities, a Mar-a-Lago gala is one of the biggest fundraising events of the year.

'It’s definitely one of our highest-visibility events,' says Erik Levis, communications director for the American Friends of Magen David Adom. Revenue from the Mar-a-Lago event is comparable to dollars brought in through the charity’s galas in Los Angeles and New York City, he adds.

Many charities say the financial benefits of continuing to hold events at Mar-a-Lago make it difficult to consider moving them elsewhere.

The Chronicle did quote one expert who raised the possibility of conflicts of interest.

Doug White, a philanthropy adviser, is more blunt, arguing that charities should shun the venue because, on its face, renting a club owned by the president presents a conflict of interest.

Even if a charity does not intend to curry favor with the president, some people may perceive it that way, he says. 'It’s the symbolism of it more than the actual cash in [Mr. Trump’s] pocket for me,' Mr. White says.

However some argued that any conflict of interest were small, given Mr Trump's vast wealth

The president, who has declined to divest from his vast business holdings, could profit from some of the events held by charities at Mar-a-Lago — but only marginally.

Some further argued that holding any single event at Mar a Lago could not influence Mr Trump all that much.

If nonprofits hold events at Mar-a-Lago to influence Mr. Trump, that would be a bad tactic, says Leslie Lenkowsky, professor emeritus of public affairs and philanthropic studies at Indiana University. He notes that Mr. Trump earns profits in many ways from his businesses; charity events held at the club are small potatoes.

'Any charities that say ‘Let’s go do our fundraiser at Mar-a-Lago because Donald Trump will be grateful to us for the business’ is probably mistaken,' says Mr. Lenkowsky, a Chronicle of Philanthropy columnist....

It's fascinating that Mr Lenkowsky basically made his argument from a cost-effectiveness standpoint. This was underlined by another expert,

For many charities, the decision comes down to the bottom line. Phil Hills, president of the Marts & Lundy fundraising consulting firm, says that while charities should consider the potential for blowback among their supporters when selecting a venue like Mar-a-Lago, money should be the biggest consideration. 'You should probably hold it at whatever location gives you the best return,' he says.

So, this seemed to be an argument that non-profit organizations should not be concerned that holding fundraisers at a Trump venue could appear to be attempts to buy influence, as long as the fundraisers bring in a lot of money.

On the other hand, arguments used against specific organizations paying the Trump Organization to hold their charity events had more to do with how Mr Trump's stated policies, now elaborated more after as his presidency wore on, conflicted with the organizations' missions. For example, an August 10, 2017 Cleveland.com article about the next Cleveland Clinic Mar a Lago fundraiser stated,

Whereas the primary complaint early this year was about Trump's immigration policy, it is about health care now.

Holding a fundraiser at Mar-a-Lago 'is unacceptable because it symbolically and financially supports a politician actively working to decrease access to health care and cut billions of dollars in research funding from the National Institutes of Health budget,' says the online petition, signed by more than 1,100 people since late July.

A social and fundraising event that helps enrich the private business interests of Trump should be contrary to the Clinic's core values, supporters of the protest say.

'Donald Trump has come out and said he would let the Affordable Care Act implode,' said Sandy Theis, executive director of Progress Ohio, one of the organizations helping circulate the letter on the website Medium. 'So there should be no health care provider, let alone major medical institution, putting money in that man's pocket.'

Note that the arguments against the Mar a Lago fundraiser were not that it would be wrong to "enrich the private business interests of Trump." The arguments were that it would wrong to enrich Mr Trump given that Trump's policies were perceived to be bad for health care. This implies it would be acceptable to enrich Mr Trump if he were perceived to have more favorable policies.

That is really striking, and strikingly cynical. It suggests that fundraisers at Mar a Lago are intended to buy influence, and hence are not merely conflicts of interest, but corruption. But it further suggests it is not worth purchasing such influence from someone who already opposes the purchaser's policies. This could translate to: it is not worth trying to corrupt someone who is already your enemy.

Eileen Sheil, executive director of corporate communications at the Clinic, did not clearly refute the implication that they were paying Mr Trump to influence him, saying only

'In no way is this about politics for us,' she said, adding that the Clinic is a nonprofit organization. 'The sole purpose' of the Mar-a-Lago event 'is to raise money.'

We Can't Do Business with, or buy the Influence of a Nazi Sympathizer

What finally undercut President Trump's business of selling the Mar a Lago venue for fundraising to health care non-profits which must have major interactions with the executive branch of the US government was not concerns about conflicts of interest, or the risks of corruption. What ruined this year's gala business was the apparent heinousness of Mr Trump's political affinities.

As we noted here, after a rally by people openly carrying Nazi and Ku Klux Klan symbols, chanting slogans from Nazi Germany (e.g., "blood and soil," the translation of the old Nazi "blut and boden," look here), one of the apparent neo-Nazis ran down counter-protesters with his car, killing one and injuring many more, Mr Trump initially refused to label the car driver and his associates as neo-Nazis or white supremicists. Days later, after an unconvincing scripted oration, he declared that some neo-Nazis and white supremicists are "very fine people," earning the praise of former Ku Klux Klan leader David Duke (look here).

That did it. Sonn after, the Cleveland Clinic announced that it "has decided that it will not hold a Florida fundraiser at Mar-a-Lago in 2018," (look here). The public announcement did not elaborate on the reason. That same day, the Palm Beach Post reported that

Laurel Baker, executive director of the Palm Beach Chamber of Commerce, minced no words Thursday about whether charities should continue to hold their events at Mar-a-Lago this season following President Donald Trump’s statements about the recent violence in Charlottesville, Va.

'If you have a conscience, you’re really condoning bad behavior by continuing to be there,' Baker said. 'Many say it’s the dollars (raised at the events) that count. Yes. But the integrity of any or organization rests on their sound decisions and stewardship.'

Within days, health related non-profit organizations including the American Red Cross, the Susan G Komen Foundation, the Autism Project of Palm Beach County, the American Friends of Magen David Adom (an Israeli emergency medicine service), and the American Cancer Foundation had cancelled their Mar a Lago events, per the Washington Post. (Note that Dana-Farber had already announced it would not do a 2018 fundraiser there.)

So the bottom line appears to be that for health care organizations, generating conflicts of interest affecting political leaders, and buying political influence is unacceptable - if the political leaders are Nazi, Ku Klux Klan, or white supremicist sympathizers.

Summary

To what depths we have fallen. The entire discusson of health care organizations continuing to hold gala fundraisers at a venue owned by the President of the United States of America seemed to assume that it is acceptable to do so to buy influence, i.e., that it is acceptable for health care organizations to purposefully generate conflicts of interest, to even corrupt politicans. The only thing they should not do is buy influence from Nazis and the like.

If our only rule is Nazis are bad, count on continuing cynicism and resulting corruption will continue to generate Nazis, or their relatives.

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